Jake Robinson

: Bodmin Road Healt!
‘ Bodir

¢

h

29 December 2015

Miss J Kearsley
Area Coroner

H M Coroner
Manchester South
Ce" ser’s Court

Fe

Tel: 0161 96
Fax: 0161 90
E-mail: bodminroad, healthcentre@

Website: www.bodminroadhealthcentre

i Mvdnt Tabor Street

Stockport
SK1 3AG

Dear Miss Kearsley

Ret ilar Jake Robinséi/[Deceased)

DOB: (03-Mar-1952) —

Thank you for your Regulation 28 Report regarding this young man’s death. | note your concerns in

Se in 5(i), which appeared particularly to be related to our practice. In response ! enclose the letter
hich was sent or at Trafford Drug Services on the 30" of June 2015
confirming that it was me ically acceptable for Jake to be started ona detox programme. You will note

that the fax has been recorded as going through. | would also point out that your comment about the
letter not being provided in evidence is in my opinion erroneous. ti was in fact included in 25 pages of
documentation sent to your office by fax on the 24" of August 2015 as part of your offices initial
request for information. it was therefore not deemed necessary to duplicate the information in my
letter to you on the 9" of September. | hope this clarifies our practices role in this matter but if you
would like further information please do not hesitate to contact me.

As a general point, | fully understand your concerns re the disconnection and boundaries between

community Mental H

lealth Services, Phoenix Futures, Trafford AIM and Primary Care Services in

Trafford. My personal concern for a number of years has been for patients like Jake with what is
ocosely termed a “dual diagnosis” which effectively means a person with mental health issues in
iddition to, or secondary-to, alcohol or substance misuse. It is | think widely recognised by Primary

care Practitioners tha
nanage this type of p.

t Community Mental Health Services are extremely reluctant both to see and
atient. The result is that they are, in my opinion, often suboptimally managed by

vhichever drug and alcohol services which happened to have been commissioned at the time.

Page 1 of 2

’
A

; fe: Mr Jake Robinson (Deceased)

DOB: a ~DOD a
;

i
q
j
i
a
}

RR a Re a

Page 2 of 2

As a practice we have obviously recorded Jake’s death as a Significant Event and have discussed the
situation fully. We found that a request to discuss Jake’s situation with his mother in June of 2015 was
overlooked due to emails from her being received whilst | was on holiday, a written apology has
already been sent to Jake’s mother regarding this. The only other action that the practice in our
opinion should perhaps have taken was to arrange a visit or consultation with Jake after his second
admission to A&E on the 17™ of July 2015. ,

In conclusion, the RAID Team stated that in their opinion there was no evidence of acute mental illness
and that his primary concern currently was illicit drug use. At that time their plan included leaving him
under the care of Phoenix Futures as he had a good rapport with his keyworker, he was discharged
from RAID with it being stated that he was aware of crisis pathways. In retrospect however we were
not aware of when his next appointments were and who they were going to be with. | am not sure
whether availing ourselves of this information would have made a major difference but it is certainly
something we will reflect on further.
ue
Yours sincerely

Enc — copy letter to Trafford Drugs Service

NHS
England

Miss J Kearsley Medical Directorate
Area Coroner NHS England - North
Coroner’s Court Lancashire & Greater Manchester
1 Mount Tabor Street 4" Floor
Stockport 3 Piccadilly Place
SK1 3AG Manchester

26 February 2016

Dear Miss Kearsley
Re: Jake Robinson (Deceased)

| have now had the opportunity to review and to consider the responses received
from Bodmin Road Health Centre, Greater Manchester West Mental Health
Foundation Trust (GMW), Salford Clinical Commissioning Group (CCG), and
Trafford Clinical Commissioning Group (TCCG). These set out the detail of the
relationships between the providers, the commissioners and the patient.

Greater Manchester West Menta! Health Foundation Trust have verified that they do
not have any record of the faxed letter sent by the Bodmin Road Health Centre
Practice, relating to the clinical advice that would have allowed Jake to maintain his
treatment for benzodiazepine addiction. To remedy this, Greater Manchester West
Mental Health Foundation Trust have undertaken a serious incident review and have
implemented systems to capture and act upon letters or faxes received. The Bodmin
Road Health Centre has similarly noted risks and taken steps to manage urgent
correspondence and to confirm actions. Greater Manchester West Mental Health
Foundation Trust have identified that their initial review of the case did not identify
the missing letter, despite Jake’s mother raising this specifically. Greater
Manchester West Mental Health Foundation Trust has noted this within their internal
review.

Salford CCG, as the lead Commissioner with Greater Manchester West Mental
Health Foundation Trust have identified that the two services, namely Phoenix
Futures and Trafford AIM provide different services to different client groups and that
the relationship between the two can be improved. | note that a Dual Diagnosis
Steering Group has been set up by local commissioners to review this. Greater
Manchester West Mental Heaith Foundation Trust acknowledges that the
Community Mental Health Team could have attended an appointment jointly with
Trafford AIM to improve engagement and assessment for Jake.

In order to reduce the risks of recurrence of a similar incident at these and other
organisations across Greater Manchester so that referrals are managed and
monitored by the responsible commissioning and provider organisations | intend to
undertake the following actions by 29 April 2016.

I will send a reminder letter to all GPs outlining best practice when sending urgent
correspondence. That is, the practice should make contact by telephone, or
otherwise, to obtain timely verification that the urgent letter or fax has been received
and to note this within records, and not to rely solely on the sender's fax confirming
transmission. This letter will also include guidance on suicide prevention and the
need to note the risk, irrespective of any previous understanding by the recipient, so
long as that risk persists.

| will also ensure that a letter is sent to all mental health service commissioners
outlining NHS England expectations that commissioned services must establish
arrangements for the following:

a. How urgent correspondence is handled and acted upon. This is also a
contractual obligation which will be monitored by the commissioner.

b. To provide assurance to the commissioner on the robustness of clinical
risk assessment tools, particularly in relation to risk to self and
historical events.

c. Where different services / service providers interface, to ensure that
the structured management for shared care is clear and unambiguous.

d. Undertake a review of systems that are in place to track and establish
lessons learned from any incidents and near misses.

e. To review policies and procedures for vulnerable patients who have a
propensity to miss appointments. .

If you have any queries in respect of the above please do not hesitate to contact me.

Yours sincerely
Xe
|

Medical Director, Lancashire & Greater Manchester
Director of Commissioning, Lancashire

Greater Manchester West NHS

Mental Health NHS Foundation Trust
Trust Management Cfiices

1 Floor, The Curve
Bury New Road

— % Mi hest

05 FEB 2016

8'" February 2016 i - HW bese Web: www.gmw.nhs.uk
: WE ARE SOCIAL

Miss J Kearsley £4 8 Retin

HM Coroner Manchester South
Area Coroner

Coroners Court

1 Mount Tabor Street
Stockport SK1 3AG

Dear Mrs Kearsley
Re Regulation 28: Jake Robinson (deceased)
| am responding to the Regulation 28 you issued to the Trust on 17/12/15.

Following the outcome of the Trust’s Serious Incident Review into the death of Jake and the
subsequent inquest, a number of actions have been taken.

You note a concern that there was no indication in the review by Greater Manchester West (GMW)
as to whether a letter had been received by Drug Services and if not, why not?

| can confirm that the Serious Incident Review Team and Trafford Aim were unaware that a letter
t to Trafford Aim until the issue was highlighted in a meeting with the reviewer lead and
after the conclusion of the review. Trafford Aim have carried out a robust search of
both its office base and the electronic database and have found no evidence to indicate the faxed

letter from the GP had been received.

A fax is usually sent when information is required quickly it is good practice in accordance with
Information Governance processes _ in an attempt to maintain confidentiality for the sender to alert
the recipient of the fax to it being sent and subsequently for the sender to confirm with the service
that it has been received. As the GP practice did not do this the service were unaware that a faxed

letter had been sent.

Trafford Aim however have taken the opportunity to review their administration process regarding
receipt of letters and faxes sent to the service. A more streamlined process has been put in place
which has reduced the points at which a letter or fax may get lost.

The Trust encourages reviewer leads to give all parties, who maybe involved in the serious incident,
the opportunity to be involved in Serious Incident Review process, including GPs. If the reviewers
had invited the GP to contribute to the process and the GP took this opportunity, it is likely the issue
of the missing letter would have come to light and have been included in the review. The Trust will
continue to highlight to review leads through training events and local guidance the importance of
ensuring all key agencies and professionals such as GPs are invited to contribute to the GMW

review process where appropriate.

The Trust is committed to safeguarding children, young people and vulnerable adults and
requires all staff and volunteers to share this commitment.

oe

Triangle of Care
MEMBER **

Greater Manchester West Mental Health NHS Foundation Trust, Trust Headquarters,
Bury New Road, Prestwich, Manchester M25 3BL Tel: 0161 773 9121.

PF Chief Executive: Bev Humphrey

Greater Manchester West INHS|

Mental Health NHS Foundation Trust

At the start of the review process the reviewers met with Jake’s mother, who initially
did not raise the issue_of the letter with the reviewers. However an interrogation of the reviewers’
email has shown that sent several emails to the reviewers and the missing letter was

mentioned in one of them amongst other subjects. The reviewers missed the pag iL and
sincerely apologise for this error. The missing letter was subsequently raised by ina

meeting with the reviewers following the completion of the report, and the reviewers took steps to
establish its whereabouts, and were able to conclude that Trafford Aim did not have possession of it.

A further concern is raised in that Phoenix Futures have no ability to prescribe medication to their
service users and have to access Trafford Aim for this, leading to a disconnected approach to

dealing with Jake’s difficulties.

Trafford Aim is an advice, recovery and treatment service for adults over 25 with dependent drug or

alcohol use.

Phoenix Futures is a service that is commissioned by Trafford Local Authority to provide psycho
social interventions to individuals with alcohol problems and those under 25 with substance misuse

problems.

Both Phoenix Futures and Trafford are commissioned to meet the needs of different groups of
service users however they work closely together.

The number of service users under the age of 25 who require medical intervention and treatment for
a drug problem is very small. However, the Trust recognises that on occasion this can occur and
has an established protocol between both services that allows those service users under the age of
25, who require a medicines review, to quickly assess the service. All efforts to reduce duplication

and streamline the pathway for the service user are made.

As part of the review Trafford Aim identified that Jake should have been booked straight in for a
medical review. Instead however, he was booked in for an assessment with a non medical member
of staff. This was inappropriate as the assessment provided by Phoenix Futures had been carried
out and a clear need for a medical review established. All staff have been reminded of the

established protocol.

The Trust acknowledge that whilst this process and close working relationship between Trafford Aim
and Phoenix Futures exist, the disjointed nature of the commissioned services is not ideal. The
Trust had developed a Dual Diagnoses Steering Group to review how these services and mental
health services work together. There has already been two planning meetings. The aim is to
ensure effective partnership working by collocating services, effective joint assessment and joint

working of cases with dual diagnosis.
Trafford alcohol and drug services will be retendered in April 2017. The Trust are hopeful that this

will provide an opportunity to develop a lead provider model which will mitigate against the
difficulties you describe. The Trafford Commissioner is aware of these concerns and is also

organising a multiagency review.

Finally you note that an explanation is needed in the review as to why the appointment clash
between Trafford Aim and the CMHT led to the appointment with CMHT being rearranged.

The Trust is committed to safeguarding children, young people and vulnerable adults and
requires all staff and volunteers to share this commitment.

Greater Manchester West Mental Health NHS Foundation Trust, Trust Headquarters,
Bury New Road, Prestwich, Manchester M25 3BL Tel: 0161 773 9121.

Triangle of Care
MEMBER & &

Chair: Alan Maden Chief Executive: Bev Humphrey

Greater Manchester West NHS)

Mental Health NHS Foundation Trust

The appointment at the CMHT was for an assessment by a qualified mental health practitioner and
not an appointment with a psychiatrist. Due to the specialised area and knowledge required to treat
drug problems, a general adult psychiatrist would not have the knowledge and expertise to prescribe
for Jake’s drug problem. Given this context and the fact that Jake had previously informed the
CMHT he wished to prioritise appointments with Phoenix Futures and Trafford Aim, the CMHT

cancelled their appointment.

The CMHT however did not consider the fact that they could have also attended the appointment at
Trafford Aim in order to facilitate an assessment and engage Jake in the service. They also did not

discuss the clash of appointments with Jake or Trafford Aim.

The CMHT now have dedicated duty workers whose role it is to solely provide an assessment and
duty worker role function. The duty workers have been reminded of the need to consider alternative
ways to carry out an assessment and it is hoped that the consistency of duty workers means that
when a dual diagnosis referral is received there will be a more consistent response to engaging

service users in the assessment process.

| hope this response provides assurance to Jake’s family and yourself that GMW have taken the
learning from Jake’s death very seriously and have put in place measures to ensure safe and
effective services.

Yours sincerel

Bev Humphrey
Chief Executive

The Trust is committed to safeguarding children, young people and vulnerable adults and
requires all staff and volunteers to share this commitment.

oe

Triangle of Care
MEMBER *& or

Greater Manchester West Mental Health NHS Foundation Trust, Trust Headquarters,
Bury New Road, Prestwich, Manchester M25 3BL Tel: 0161 773 9121.

Chair: Alan Maden Chief Executive: Bev Humphrey